Why Complex Claims Demand a Blend of AI, Automation, and Personal Expertise

Posted August 29, 2023 by Jason Wallis

While technology continues to be the driver of change, we operate in an industry that demands human interaction to provide emotional support and a personal touch to patients. Telehealth, mobile apps, and artificial intelligence-driven healthcare claims processing are among the innovations that are helping providers meet rising service expectations of tech-savvy healthcare consumers.

AI (artificial intelligence) and automation continue to revolutionize operational efficiency. However, does overreliance on technology undermine the patient’s experience in moments that matter most, requiring providers to balance integration of efficiency-enhancing automation with differentiating personal service? Striking that balance likely means expanding capabilities and roles of healthcare professionals to extend beyond the foundational, technical, clinical, and operational perspectives.

The pressure is always to augment claims processing with new technologies and data sources that can increase efficiency, productivity, and accuracy since every dollar recouped goes straight to the bottom line. But, as powerful as these tools are, they still cannot replace the invaluable role of human expertise, especially when navigating healthcare complex claims.

This isn’t an either/or choice between technology or people. Providers should continue bolstering their data sources and technology infrastructure to process claims faster, more accurately, and at lower costs, while also offering continuing education to their claims professionals. That way, they could maximize the value of all the newly integrated technology and data available while still being able to curate a personalized patient experience.

Here’s why a balanced blend is essential:

The Nuances of Human Behavior

Hospital claims frequently involve personal experiences: accidents, miscommunications, or unexpected circumstances. Most commonly, hospital claims are managed by the revenue cycle management team, a clearinghouse, or a chargemaster system to ensure they are properly handled and formatted for specific payers, delivered to the right place, and optimized for the highest reimbursement. Then, the claim goes to the payer, which sends them out for repricing, editing and sometimes out-of-network negotiation. Claims can be denied in full or in part, bundled, or unbundled, ultimately delaying payment to a provider.

While AI and automation can sift through data and process standard cases with unmatched speed and accuracy, the ability to effectively balance AI, automation, and personal expertise may seem unrealistic for a provider. Finding a trusted expert who has successfully integrated all three components, like EnableComp, can alleviate challenges for health systems nationwide.  Our team of experts works with our proprietary software, Enforcer360 to deliver claims to the right payer at the right time for the right amount. Despite our technology being a primary differentiator for success, we still understand the tool won’t solve everything.  Our revenue specialists go through continuous training to stay informed of the latest changes, and, when needed, pick up the phone and call the correct payer to resolve the issue.  

The Ever-Evolving Landscape of Regulations

Complex claims operate within a maze of unique state and national regulations, which are most often subject to frequent updates. Staying abreast of these legislative and regulatory activities is as important as ever.

Responding to new or changing regulations is a persistent challenge for healthcare providers, and it is one that is not fading away anytime soon. Most importantly, regulators are continuing a trend to emphasize innovation in healthcare and make it easier for nontraditional players to enter the healthcare space, laying the groundwork for continual disruption.

Automation can track and apply these regulations with precision, but interpretation often requires a human touch. We recognize the number of resources and extensive knowledge it takes to stay informed of these changes. We employ a full team of Managed Care experts, ranging from nurses, to coders, to attorneys, to ensure that claims are processed in alignment with the latest standards, leveraging both automation for accuracy and human expertise.

The Limitation of Algorithms

While algorithms process vast amounts of data with incredible speed, they are bound by existing data patterns. Unique situations or challenges can sometimes trip them up. We have experts on staff with more than 30 years of experience, who can identify solutions or connections that might elude an automated system. Intuition and judgment, honed over time, are irreplaceable.

AI algorithms are only as objective as their data sets, which limits the ability to understand the context in which medical decisions are made. If the data used to train the AI is incomplete, the generated results may also lack accuracy and comprehensiveness leading to potentially incorrect or discriminatory outcomes.

Continuous Learning and Adaptability

Modern AI systems have the ability to learn and adapt with any amount of data, minimum or vast, but humans can learn from singular instances, feedback, or even interdisciplinary insights. In complex claims without many precedents, the adaptability of a human expert complements the consistent data-driven approach of AI and automation.

The allure of AI and automation in the claim recovery process is undeniable, bringing speed, consistency, and scalability to the table. However, complex claims aren’t merely about following an algorithm.

At EnableComp, we pride ourselves on this harmonious approach. We leverage best-in-class AI and automation for efficiency while our expert team provides the insight, understanding, and adaptability that only humans can offer. This combination ensures that we navigate the intricate world of complex claims with both finesse and precision, always striving for the best outcomes for our clients.

Providers should only have to focus on providing the highest quality of care to their patients and their communities. Our focus is to be an expert partner down the hall generating revenue to enhance the bottom line.

For more information on how EnableComp can help you manage your complex claims with technology and a human touch, email us at contact@enablecomp.com or visit us at enablecompcom.wpenginepowered.com.